Emergency Department Care denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services. Findings: The physician reviewer found that the patient presented to the emergency department. He reported three days of crampy abdominal pain with repeated vomiting. He denied fever, diarrhea, or dysuria. The patient admitted to recent binge alcohol drinking. His past medical history included cyclic vomiting syndrome, Helicobacter pylori, as well as cannabis use. He had a past history of endoscopy and colonoscopy procedures. His vital signs revealed a pulse of 104, blood pressure of 119/63, respirations of 16, and a temperature of 97.8. The patient appeared mildly distressed. His abdomen was soft without tenderness, rebound, or guarding.

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested for emergency services. Findings: The physician reviewer found that at issue in this case is whether a prudent layperson in the patient’s circumstances would have sought immediate medical attention. California law defines an “emergency medical condition” as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patient’s health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: A 29-year-old female enrollee has requested reimbursement for emergency services. The patient is a 29-year-old female with a medical history significant for Crohn’s disease who presented to the emergency department with severe abdominal pain. The pain had been present for 1.5 weeks but had worsened over the prior two days. She was treated and discharged earlier the same day in an in-network emergency department. She was reportedly diagnosed with inflammation in her colon and was to follow-up as an outpatient with her provider. Her pain was noted to be 10/10 in severity at the time of presentation. Her emergency department evaluation included a complete blood count, chemistries, urinalysis, pregnancy test, lipase level and review of the computed tomography (CT) scan results from the earlier emergency room visit.

A 27-year-old female enrollee has requested emergency services for the treatment of her medical condition. Findings: The physician reviewer found that an emergency is the sudden onset of symptoms of such severity that a prudent layperson would believe her health to be in jeopardy without immediate medical attention. This patient had evidently suffered a dislocation of her left TMJ disc. It had occurred sometime during the week prior to her visit. When she presented to the Emergency Department, the patient was able to eat, swallow and breathe without difficulty. She had not sustained any recent trauma. Although her symptoms were not improving, they had not suddenly worsened. A unilateral or bilateral condylar dislocation can be manually reduced in the Emergency Department, but that was not the diagnosis in this patient.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Emergency Department Care, then check the rights and deadlines that apply to your plan.